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Background: Against a backdrop of more than four decades of war, conflict and insecurity, Afghanistan is recognised as suffering from endemic violence and children are exposed to multiple forms of violence, including at the family and school levels. This paper presents the results of an evaluation of school-based peace education and a community-based intervention to change harmful social norms and practices related to gender and the use of violence in conflict resolution, implemented in Afghanistan with the aim of reducing violence against and between children. Methods: The evaluation consisted of a cross-sectional, interrupted time series design with three data collection points over 12 months. Data was collected from students in 11 secondary schools (seven girls’ and four boys’ schools) in Jawzjan province of Afghanistan, with a total of 361 boys and 373 girls sampled at endline. All children were interviewed with a questionnaire developed for the study. Key outcomes included children’s experience of peer violence (both perpetration and victimization) at school, corporal punishment both at home and at school, and observation of family violence. Other outcomes included children’s gender equitable attitudes, attitudes towards child punishment, depression and school performance. Results: Between baseline and endline evaluation points, there were significant reductions in various forms of violence at the school level, including both boys’ and girls’ past month experience of peer violence victimization, peer violence perpetration, and corporal punishment by teachers. There were also significant reductions in boys’ and girls’ experience of corporal punishment at home and observation of family violence, with a particularly strong effect observed among girls. Both boys and girls had significantly more equitable gender attitudes and significantly less violence-supportive attitudes in relation to children’s punishment, and significantly fewer symptoms of depression. Girls’ school attendance was also significantly higher at endline. Discussion: To our knowledge this is the first time that a peace education program has been evaluated in Afghanistan, with or without a community intervention to change harmful social norms and practices related to gender and the use of violence for conflict resolution. The evaluation suggests that the intervention may have led to a reduction in various forms of violence, including children’s peer violence, corporal punishment of children both at school and at home, and in children’s reports of domestic violence against women at the household level. [ABSTRACT FROM AUTHOR]

Background: Four decades of conflict has indelibly impacted the lives of Afghans, exposing many to different forms of trauma. The aim of this paper investigate a hypothesis that (mostly war related) trauma is a key driver of partner violence in Afghanistan. Methods: 1,463 women aged 18–48 were recruited into a randomised controlled trial (RCT) to evaluate a women empowerment intervention in 8 villages of Kabul and Nangarhar provinces. The women were interviewed at baseline. The analysis uses multivariable logistic regression and structural equation modelling (SEM) to describe relationships between measures. Results: 57.4% of women reported exposure to one of four types of trauma: 23.3% an armed attack, 39.4% had felt close to death, 10.6% witnessed a friend or family member being killed and 21.4% witnessed the death of a stranger or someone unknown. Trauma exposure was associated with being older, Pashtan, madrassa educated, and food insecure. Women who were trauma exposed were more likely to have ever experienced IPV, have hit their children in the last 4 weeks, and be hit by a sibling or relative of their husband or their mother-in-law in the last year. They held less patriarchal personal gender attitudes and perceived the community to be more patriarchal. The SEM showed that all pathways between trauma exposure and IPV were ultimately mediated by either (mostly mental) ill-health or quarrelling, but not both of these. There were multiple paths through which trauma exposure impacted women’s past year experience of physical IPV. One was mediated by childhood trauma exposure and a latent variable for ill health. Other paths were mediated by women’s education and personal gender attitudes and ill-health, or else by quarrelling. Trauma exposure was related to lower educational levels. Another path was mediated by less patriarchal personal gender attitudes and ill health. Community gender attitudes was a mediating variable on a path which was also mediated by ill health and another mediated by quarrelling. It was also a mediator on a path which included personal gender attitudes and ill-health. Food insecurity mediated another path with ill health. It was also connected to childhood trauma, community gender attitudes and educational level. Conclusion: Trauma exposure due to conflict will persist until the conflict ends but the impact on women can be ameliorated. This analysis suggests interventions to reduce women’s exposure to IPV should focus on reducing poverty, changing social norms on gender, providing relationship skills to help reduce quarrelling and supporting women’s mental health. [ABSTRACT FROM AUTHOR]

Background: Anorexia nervosa (AN) is a complex and heritable psychiatric disorder, which imposes significant mortality and morbidity on sufferers globally. We aimed to report the prevalence, incidence and disability-adjusted life-years (DALYs) attributable to AN in the Middle East and North Africa (MENA) region by age, sex and socio-demographic index (SDI), between 1990 and 2019. Methods: The disease burden attributable to AN was obtained for the 21 countries located in the MENA region between 1990 and 2019 using publicly available data from the Global Burden of Disease (GBD) 2019 study. All estimates were provided as counts and age-standardized rates per 100,000 population, along with 95% uncertainty intervals (UIs). Results: In 2019, the estimated age-standardised point prevalence and incidence rate of AN (per 100,000) in MENA were 49.3 (95% UI: 34.6–70.4) and 16.0 (11.3–22.0), which were 11.4% (7.3–15.4) and 5.9% (2.6–9.1) higher than in 1990, respectively. Furthermore, the regional age-standardised DALY rate was 10.6 (6.3–17.0) per 100,000 in 2019, which was 11.8% (5.2–19.1) higher than in 1990. In 2019, Kuwait [17.3 (10.3-27.9)] and Afghanistan [6.3 (3.7-10.3)] had the highest and lowest age-standardised DALY rates, respectively. In addition, Iran showed the largest increases in the age-standardised point prevalence [30.0% (24.1–36.2)], incidence [24.6% (18.6–30.4)] and DALY [30.5% (22.6–38.9)] rates between 1990 and 2019. In 2019, the number of prevalent cases and prevalence estimates peaked in the 15–19 age group for males and the 20–24 age group for females, with females having a higher number of cases and prevalence in all age groups. In 2019, the age-standardised DALY rates in MENA were higher than the global rates among males aged 10–34 years, but were lower than the global estimates among females in almost all age groups. In addition, the burden of AN was positively associated with the level of socio-economic development during the measurement period. Conclusions: The burden of AN in the MENA region increased between 1990 and 2019, which indicates that it is likely to become a more serious public health issue in the future. Up-to-date information about the epidemiological trends in the region would allow health policymakers to make informed and appropriate decisions to help address this issue. Plain English summary: The findings of the present study showed that the point prevalence and incidence rate of anorexia nervosa have increased in the Middle East and North Africa region between 1990 and 2019. The highest burden in 2019 was found in Kuwait, while Afghanistan had the lowest attributable burden. In addition, between 1990 and 2019 Iran had the largest increase in the point prevalence of anorexia nervosa. Also in 2019, anorexia nervosa was more prevalent in females and peaked in the 15–19 age group for males and the 20–24 age group for females. Furthermore, as the level of socioeconomic development increased, so did the burden attributable to anorexia nervosa. [ABSTRACT FROM AUTHOR]

Stroke is one of the leading causes of mortality and morbidity across the globe. Providing comprehensive data on the burden of stroke in the Middle East and North Africa (MENA) could be useful for health policy makers in the region. Therefore, this article reported the burden of stroke and its attributable risk factors between 1990 and 2019 by age, sex, type of stroke, and socio-demographic index. Data on the point prevalence, death, and disability-adjusted life-years (DALYs), due to stroke, were retrieved from the Global Burden of Disease study 2019 for the 21 countries located in the MENA region from 1990 to 2019. The counts and age-standardised rates (per 100,000) were presented, along with their corresponding 95% uncertainty intervals (UIs). In 2019, the regional age-standardised point prevalence and death rates of stroke were 1537.5 (95% UI: 1421.9–1659.9) and 87.7 (78.2–97.6) per 100,000, which represent a 0.5% (− 2.3 to 1.1) and 27.8% (− 35.4 to − 16) decrease since 1990, respectively. Moreover, the regional age-standardised DALY rate in 2019 was 1826.2 (1635.3–2026.2) per 100,000, a 32.0% (− 39.1 to − 23.3) decrease since 1990. In 2019, Afghanistan [3498.2 (2508.8–4500.4)] and Lebanon [752.9 (593.3–935.9)] had the highest and lowest age-standardised DALY rates, respectively. Regionally, the total number of stroke cases were highest in the 60–64 age group and was more prevalent in women in all age groups. In addition, there was a general negative association between SDI and the burden of stoke from 1990 to 2019. Also, in 2019, high systolic blood pressure [53.5%], high body mass index [39.4%] and ambient particulate air pollution [27.1%] made the three largest contributions to the burden of stroke in the MENA region. The stroke burden has decreased in the MENA region over the last three decades, although there are large inter-country differences. Preventive programs should be implemented which focus on metabolic risk factors, especially among older females in low SDI countries. [ABSTRACT FROM AUTHOR]

Background: A common means of vaccination coverage measurement is the administrative method, done by dividing the aggregated number of doses administered over a set period (numerator) by the target population (denominator). To assess the quality of national target populations, we defined nine potential denominator data inconsistencies or flags that would warrant further exploration and examination of data reported by Member States to the World Health Organization (WHO) and UNICEF between 2000 and 2016. Methods and findings: We used the denominator reported to calculate national coverage for BCG, a tuberculosis vaccine, and for the third dose of diphtheria-tetanus-pertussis-containing (DTP3) vaccines, usually live births (LB) and surviving infants (SI), respectively. Out of 2,565 possible reporting events (data points for countries using administrative coverage with the vaccine in the schedule and year) for BCG and 2,939 possible reporting events for DTP3, 194 and 274 reporting events were missing, respectively. Reported coverage exceeding 100% was seen in 11% of all reporting events for BCG and in 6% for DTP3. Of all year-to-year percent differences in reported denominators, 12% and 11% exceeded 10% for reported LB and SI, respectively. The implied infant mortality rate, based on the country’s reported LB and SI, would be negative in 9% of all reporting events i.e., the country reported more SI than LB for the same year. Overall, reported LB and SI tended to be lower than the UN Population Division 2017 estimates, which would lead to overestimation of coverage, but this difference seems to be decreasing over time. Other inconsistencies were identified using the nine proposed criteria. Conclusions: Applying a set of criteria to assess reported target populations used to estimate administrative vaccination coverage can flag potential quality issues related to the national denominators and may be useful to help monitor ongoing efforts to improve the quality of vaccination coverage estimates. [ABSTRACT FROM AUTHOR]

Background: Designing effective public health campaigns in areas of armed conflict requires a nuanced understanding of how violence impacts the epidemiology of the disease in question. Methods: We examine the geographical relationship between violence (represented by the location of detonated Improvised Explosive Devices) and polio incidence by generating maps of IEDs and polio incidence during 2010, and by comparing the mean number of IED detonations in polio high-risk districts with non polio high-risk districts during 2004–2009. Results: We demonstrate a geographic relationship between IED violence and incident polio. Districts that have high-risk for polio have highly statistically significantly greater mean numbers of IEDs than non polio high-risk districts (p-values 0.0010–0.0404). Conclusions: The geographic relationship between armed conflict and polio incidence provides valuable insights as to how to plan a vaccination campaign in violent contexts, and allows us to anticipate incident polio in the regions of armed conflict. Such information permits vaccination planners to engage interested armed combatants to co-develop strategies to mitigate the effects of violence on polio. [ABSTRACT FROM AUTHOR]

Simple Summary: In modern conflicts, one of the greatest risks for military personnel is represented by explosive devices. For this reason, specifically trained dogs able to detect explosives have been more and more intensively used in humanitarian military operations. However, at present, literature regarding working problems reported by these animals is very limited. The a of this study was to evaluate the health status of military dogs participating in humanitarian missions to Afghanistan, comparing their pre- and post-mission blood work. Dogs were first considered together as a group and then divided in groups by age, sex, breed and mission length. The results of the study show that there are no particular differences between their blood work before and after the missions. This indicates that the recorded dogs were physically well prepared to face their tasks. The intergovernmental organization known as the United Nations (UN) was born "to maintain international peace and security" through different operations and tasks, including "mine action" and "explosive detection". Explosives are the most frequent cause of injuries in military personnel and an enormous danger for civilians. The role of explosive detection dogs (EDDs) and mine detection dogs has gained great consideration over time, leading to their intense use in military operations. Literature regarding working injuries reported by EDDs during missions is limited. The aim of the present study is to investigate the hematological changes that occurred between pre- and post-mission blood analyses in military working dogs deployed to Afghanistan in order to evaluate signs of health problems or physical adjustments. Examining the clinical records, only three dogs reported a medical issue, one with gastric dilatation-volvulus (GDV), and two with lameness episodes. Lack of health issues occurring during the missions was reflected by the absence of significant differences between pre- and post-mission blood analyses. Blood results were also examined by dividing the EDDs into groups considering age at departure, sex, breed and mission length. A few categories demonstrated significant changes in some parameters; however, the mean values were always included in the ranges of normality, indicating that their physical fitness and training were adequate for the required tasks. [ABSTRACT FROM AUTHOR]

The first survey designed to allow estimates of the demographic characteristics of Afghanistan's sedentary population was conducted during the period 1972-1974. Our analysis of these data, based on recently developed techniques for handling imcomplete or inaccurate data, suggests that this population lives under conditions that are extreme when judged by modern standards. Marriage is early, especially for females, and universal. Marital fertility conforms to a pattern of natural fertility and total fertility is high. The birth rate is among the highest in the world today, and the expectation of life at birth is among the very lowest. Mortality is lower in urban areas than in rural areas, whereas total fertility is approximately the same in both. Our estimates of fertility and mortality imply stable populations which match closely the observed age distributions for both the rural and urban areas. [ABSTRACT FROM AUTHOR]